How to Refer

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Case Study

“A 72 year old gentleman was referred via the SPA. He had dementia and reduced mobility following a fall, he did not want to go into hospital.

The SPA arranged a rapid home assessment, ordered a profiling bed and mattress, organised for EMAS to move the gentleman downstairs and arranged intermediate care services to go in twice a day for personal care.”

Rapid assessment service

The service is intended for frail people with syndromes associated with this such as falls, polypharmacy and reduced mobility.

This service operates in the specialist assessment &rehabilitation centre (SpARC) at London Road Community Hospital (LRCH), and is open Monday to Friday, 8.30am - 5.30pm.

Providing a geriatrician led multi-disciplinary assessment to avoid the patient getting to a crisis that may result in an attendance at the emergency department or a non-elective acute admission.

Following their assessment patients are likely to come back for a follow-up review, however on the initial assessment day, it will be determined what the patient needs in terms of managing their long-term health and social care needs safely within their own home environment.

Onward referrals to the appropriate agencies will be made, this support may come from the Trust’s integrated community health services and/or social care.

Communication will be sent back to GPs in the form of a letter detailing the actual assessment and advice with regards to ongoing management of the patient’s needs.

Multi-disciplinary team

The team within the rapid assessment is led by a geriatrician, and includes skilled:

Nursing

Physiotherapy

Occupational therapy

Skilled therapy assistants

To Refer

GPs should refer patients through Choose & Book.

If a patient is referred to the single point of access (SPA) and would benefit from a clinical multidisciplinary assessment with a DME consultant, they will be referred through to the rapid assessment service.

However, it may be that the patient is already in the early stages of deterioration and should be referred from the GP surgery, through to the rapid assessment service without any need for intervention from the SPA.

It is recommended that patients are seen within two working days, however to assist patient choice appointments slots will be opened up to seven days in advance.

Case Study

An 83 year old lady was referred to the Rapid Assessment clinic by her GP and she had an appointment within 48 hours. She had experienced multiple falls and had become vague and not feeling herself. At the clinic she was seen by the consultant geriatrician, physiotherapist, occupational therapist and nurse for a multidisciplinary assessment. She was referred for medical investigations and will be attending the clinic for strength and balance training. She was also provided with a walking aid and given advice on transfers. She was assessed to have significant memory issues previously not identified and following investigation of these, may be referred to the memory clinic.

Community beds at LRCH

These beds are available to patients registered with a Derby City GP.

The 83 beds at London Road Community Hospital (LRCH) provide a seven day inpatient step-up and step-down rehabilitation service for the frail older person.

The service is supported by local GPs with support from a geriatrician, advanced nurse practitioners, and a skilled team of qualified nursing and therapy staff.

Step-up from the home environment

There is a great emphasis to use these beds for stepping patients up from their own home setting whereby the patient requires a period of non-acute inpatient multi-disciplinary assessment and a period of rehabilitation to determine and assist their immediate & long-term needs. The primary aim is to maintain the person’s independence as long as possible.

The average length of stay is expected to be fourteen days.

Step-down from acute in-patient management

For an older person overcoming an acute period of illness, they may require a period of enablement and rehabilitation within a non-acute rehabilitation setting.

The average length of stay is expected to be fourteen days.

Holistic case management

Whilst the patient is being managed, the multi-disciplinary team will provide case management and in doing so will liaise with families, external agencies including social care, mental health, continuing healthcare and the voluntary sector.

The recent integration of community health services will ensure engagement is optimised to take part in the person’s onward care once they have been discharged from hospital, this may include:

Intermediate Care

Community Matron Service

District Nursing

To refer

Referrals and access for step-up can be made through the Single Point of Access (Derby City), see the first tab, above.